RANDOMIZED CONTROLLED TRIAL OF GENERAL-PRACTITIONER VERSUS USUAL MEDICAL-CARE IN AN URBAN ACCIDENT AND EMERGENCY DEPARTMENT - PROCESS, OUTCOME, AND COMPARATIVE COST

Objective-To see whether care provided by general practitioners to non -emergency patients in an accident and emergency department differs si gnificantly from care by usual accident and emergency staff in terms o f process, outcome, and comparative cost. Design-A randomised controll ed trial. Setting-A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessi onal basis. Patients-All new attenders categorised by the triage syste m as ''semiurgent'' or ''delay acceptable.'' 66% of all attenders were eligible for inclusion. Main outcome measures-Numbers of patients und ergoing investigation, referral, or prescription; types of disposal; c onsultation satisfaction scores; reattendance to accident and emergenc y department within 30 days of index visit; health status at one month ; comparative cost differences. Results-4684 patients participated. Fo r semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative di fference 20%; 95% confidence interval 16% to 25%), referred to other h ospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A sim ilar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) p atients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended. 435 patients (7 2% of those eligible) completed the consultation satisfaction question naire and 258 (59% of those eligible) provided health status informati on one month after consultation. There were no differences between pat ients managed by general practitioners and those managed by usual staf f regarding consultation satisfaction questionnaire scores or health s tatus. For all patients seen by general practitioners during the study , estimated marginal and total savings were pound Ir1427 and pound Ir1 17 005 respectively.Conclusion-General practitioners working as an int egral part of an accident and emergency department manage non-emergenc y accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.